Norman C. Christopher

Initial urinary epinephrine and cortisol levels predict acute PTSD symptoms in child trauma victims

BACKGROUND Previous research examining biological correlates of posttraumatic stress disorder (PTSD) in children has suggested that children with chronic PTSD have altered levels of catecholamines and cortisol compared to similarly traumatized children who do not meet diagnostic criteria. The present study extended these findings by examining whether urinary hormone levels collected soon after a trauma were related to subsequent acute PTSD symptoms in child trauma victims. METHODS Initial 12-h urine samples were collected from 82 children aged 8-18 admitted to a Level 1 trauma center. Collection was begun immediately upon admission, and samples were assayed for levels of catecholamines and cortisol. PTSD and depressive symptomatology were assessed 6 weeks following the accident. RESULTS Initial urinary cortisol levels were significantly correlated with subsequent acute PTSD symptoms (r=0.31). After removing the variance associated with demographic variables and depressive symptoms, urinary cortisol and epinephrine levels continued to predict a significant percentage (7-10%) of the variance in 6-week PTSD symptoms. Examination of boys and girls separately suggested that significance was primarily driven by the strength of the relationships between hormone levels and acute PTSD symptoms in boys. CONCLUSIONS The present findings suggest that high initial urinary cortisol and epinephrine levels immediately following a traumatic event may be associated with increased risk for the development of subsequent acute PTSD symptoms, especially in boys.

Prospective Multicenter Study of Bronchiolitis: Predicting Safe Discharges From the Emergency Department

OBJECTIVE. Bronchiolitis is the leading cause of hospitalization for infants. Our objective was to identify factors associated with safe discharge to home from the emergency department. METHODS. We conducted a prospective cohort study during 2 consecutive bronchiolitis seasons, from 2004 to 2006. Thirty US emergency departments contributed data. All patients were <2 years of age and had a final emergency department attending physician diagnosis of bronchiolitis. Using multivariate logistic regression, a low-risk model was developed with a random half of the data and then validated with the other half. RESULTS. Of 1456 enrolled patients, 837 (57%) were discharged home from the emergency department. The following factors predicted safe discharge to home: age of ≥2 months, no history of intubation, a history of eczema, age-specific respiratory rates (<45 breaths per minute for 0–1.9 months, <43 breaths per minute for 2–5.9 months, and <40 breaths per minute for 6–23.9 months), no/mild retractions, initial oxygen saturation of ≥94%, fewer albuterol or epinephrine treatments in the first hour, and adequate oral intake. The importance of each factor varied slightly according to age, but the comprehensive model (developed and validated for all children <2 years of age) yielded an area under the receiver operating characteristic curve of 0.81, with a good fit of the data. CONCLUSIONS. This large multicenter study of children presenting to the emergency department with bronchiolitis identified several factors associated with safe discharge, including cut points for respiratory rate and oxygen saturation. Although the low-risk model requires further study, we believe that it will assist clinicians evaluating children with bronchiolitis and may help reduce some unnecessary hospitalizations.

Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department.

BACKGROUND. Nonpharmacologic interventions, such as distraction, have been shown to be powerful adjuncts in reducing pain and anxiety in children with both acute and chronic painful conditions. There are no controlled studies evaluating these interventions as adjuncts to facilitate completion of painful procedures in the pediatric emergency department (ED). OBJECTIVE. We assessed the effectiveness of distraction techniques in reducing the sensory and affective components of pain among pediatric patients undergoing laceration repair in the ED. METHODS. Eligible children between 6 and 18 years of age (N = 240) presenting to the ED for laceration repair were randomly assigned to an intervention or control arm. Those assigned to the intervention arm were given a choice of age-appropriate distracters during laceration repair. Quantitative measures of pain intensity, situational anxiety, and pain distress (as perceived by the parent) were assessed by using the 7-point Facial Pain Scale, State Trait Anxiety Inventory for Children, and a visual analog scale, respectively, before and after laceration repair. The State Trait Anxiety Inventory for Children was performed in children ≥10 years of age. RESULTS. There was no difference in mean change in Facial Pain Scale scores between the control and the intervention groups in children <10 years of age. Multivariate analysis in this same age group showed that the intervention was independently associated with a reduction in pain distress as perceived by parents based on the mean change in visual analog scale scores. In older children, the intervention was independently associated with reduction in situational anxiety but not in pain intensity or in parental perception of pain distress. CONCLUSIONS. The use of distraction techniques is effective in reducing situational anxiety in older children and lowering parental perception of pain distress in younger children. This technique may have a role in improving the quality of management of procedural pain in a pediatric ED setting.

The efficacy of early propranolol administration at reducing PTSD symptoms in pediatric injury patients: A pilot study

Initial research supports the use of propranolol to prevent posttraumatic stress disorder (PTSD); research has not examined pharmacological prevention for children. Twenty-nine injury patients (ages 10-18 years old) at risk for PTSD were randomized to a double-blind 10-day trial of propranolol or placebo initiated within 12 hours postadmission. Six-week PTSD symptoms and heart rate were assessed. Although intent-to-treat analyses revealed no group differences, findings supported a significant interaction between gender and treatment in medication-adherent participants, Delta R(2) = .21. Whereas girls receiving propranolol reported more PTSD symptoms relative to girls receiving placebo, Delta R(2) = .44, boys receiving propranolol showed a nonsignificant trend toward fewer PTSD symptoms than boys receiving placebo, Delta R(2) = .32. Findings inform gender differences regarding pharmacological PTSD prevention in youth.

Ethyl Vinyl Chloride Vapocoolant Spray Fails to Decrease Pain Associated with Intravenous Cannulation in Children

The purpose of the study was to determine the effect of ethyl vinyl chloride vapocoolant spray on pain reported by children undergoing intravenous cannulation. A randomized, double-blinded, placebo-controlled trial was conducted on eligible children between the ages of 9 and 18 years seen in a pediatric emergency department and requiring intravenous cannulation. Informed consent was obtained, and children were randomized to receive ethyl vinyl chloride spray, isopropyl alcohol spray, or no spray (control group). Patient demographics and information pertaining to each intravenous cannulation were recorded. Children indicated the degree of pain associated with intravenous cannulation on a 100-mm visual analog scale (VAS) compared to a baseline pain score of “zero.” Statistical analysis was performed by using Stata version 7. One hundred twenty-seven subjects were enrolled: 37 received ethyl vinyl chloride vapocoolant spray, 48 received isopropyl alcohol spray (placebo), and 42 received no pretreatment. Mean VAS scores for pain experienced during cannulation were 34, 33, and 31 mL for each group, respectively. Ethyl vinyl chloride vapocoolant spray failed to measurably reduce pain associated with intravenous cannulation when compared to those pretreated with isopropyl alcohol spray or receiving no intervention.

Pediatric urolithiasis: clinical predictors in the emergency department.

OBJECTIVE: The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. METHODS: A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Childrens Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. RESULTS: A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. CONCLUSIONS: UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

A randomized clinical trial of oral transmucosal fentanyl citrate versus intravenous morphine sulfate for initial control of pain in children with extremity injuries.

Background: Extremity injury is a common condition that requires pain management in an emergency department. In pediatric patients, the most frequently used method of pain control is intravenous (IV) morphine sulfate. Oral transmucosal fentanyl citrate (OTFC) is a potential alternative to morphine, which may obviate the need to place an IV before addressing pain. Objective: To compare OTFC with IV morphine for sedation and analgesia during initial evaluation of children with deformity of an extremity and suspected fracture. Design/Methods: A randomized controlled trial of OTFC versus IV morphine in which 8- to 18-year-olds presenting to pediatric tertiary care emergency department with extremity deformity and suspected fracture were eligible. Only those with visual analog scale (VAS) (0 = no pain, 100 = worst pain imaginable) score equal to or greater than 50/100, and American Society of Anesthesia I or II qualified. Patients were excluded if history of loss of/altered level of consciousness, multiple traumatic injuries, or if patient had received prior medication for pain control. All patients enrolled were randomly assigned to receive either IV morphine (0.1 mg/kg) or OTFC (10-15 μg/kg). Patients rated pain intensity using VAS; scores were recorded before medicating and at 15-minute intervals after the medication was given. Adverse events such as emesis, pruritus, and respiratory depression were recorded. Results: A total of 87 patients were enrolled in study (OTFC, 47; morphine, 40). There are no significant differences between the 2 groups when comparing sex, age, weight, and pretreatment VAS score (P > 0.05). Although the VAS scores were not significantly different before medicating the patient, an analysis of variance shows that there was a significant difference (P > 0.05) in VAS scores at 30 minutes. The differences persisted for every 15 minutes through the 75 minutes of monitoring. There was no statistically significant difference between the 2 groups when comparing the number of adverse events (P = 0.23). Conclusions: The use of OTFC can provide improved pain control when compared with IV morphine. The pain reduction starts 30 minutes after initiation of medication, and the effect is seen as far as 75 minutes after the initiation of analgesic medication. The study size was too small to make any statements concerning adverse effects; thus, further studies with larger sample sizes are needed to determine the use of OTFC.

Paramedic Initiated Non-Transport of Pediatric Patients

Introduction. In a time of emergency department overcrowding andincreased utilization of emergency medical services, a highly functional prehospital system will balance the needs of the individual patient with the global needs of the community. Our community addressed these issues through the development of a multitiered prehospital care system that incorporated EMS initiated non-transport of pediatric patients. Objective. To describe the outcome of pediatric patients accessing a progressive prehospital system that employed EMS initiated non-transport. Methods. A prospective observational case series was performed on pediatric patients (< 21 years old) designated EMS initiated non-transport. Patients were designated non-transport after an initial EMS protocol driven, complaint-specific clinical assessment in conjunction with medical oversight affirmation. Telephone follow-up was completed on all consecutively enrolled non-transport patients to collect information about outcome (safety) as well as overall satisfaction with the system. A five-point Likert scale was utilized to rate satisfaction. Results. There were 5,336 EMS requests during the study period. Seven hundred andfour were designated non-transport, of which 74.8% completed phone follow-up. Categories of EMS request included minor; medical illness 43.4%, trauma 55.9%, andother 1.1%. There were 13 admissions (2.4%) to the hospital after EMS initiated non-transport designation. Admissions after non-transport had trends toward younger age (p = 0.002) andmedical etiology (p = 0.006). There were no PICU admissions or deaths. Conclusion. Our EMS system provides an alternative to traditional protocols, allowing EMS initiated non-transport of pediatric patients, resulting in effective resource utilization with a high level of patient safety andfamily satisfaction.

The Impact of Caregiver Distress on the Longitudinal Development of Child Acute Post-traumatic Stress Disorder Symptoms in Pediatric Injury Victims

OBJECTIVE The present study prospectively examined the development of child PTSD symptoms (PTSS) and the impact of caregiver PTSS on child PTSS following injury. METHODS One hundred and eighteen ED patients and their caregivers were interviewed in-hospital and 2- and 6-weeks posttrauma. Structural equation modeling and hierarchical linear regressions examined the development of PTSS. RESULTS A model combining child and caregiver 2-week PTSS into one latent family PTSS variable provided the best fit to the data. Child in-hospital avoidance symptoms predicted higher levels of 2-week family PTSS. Two-week family PTSS predicted child 6-week PTSS. Post hoc analyses revealed an interaction between in-hospital caregiver avoidance symptoms and child reexperiencing symptoms in predicting 6-week child PTSS. CONCLUSIONS Results highlight the dynamic development of child PTSS. Different symptom clusters may be related to higher PTSS at differing times posttrauma and may inform the development of time-sensitive methods of assessment and intervention for injury victims.

Serum procalcitonin concentration in the evaluation of febrile infants 2 to 60 days of age.

Objective Febrile infants younger than 60 days are at risk for serious bacterial infections (SBIs) and often undergo extensive laboratory investigation and hospitalization. We aim to determine the diagnostic value of serum procalcitonin (PCT) concentration for identification of febrile infants at low risk for SBI in comparison to the Rochester Criteria (RC). Methods Infants 2 to 60 days of age with rectal temperature 38°C were enrolled between May 2004 and March 2007. Blood was obtained from each, and PCT was assessed using BRAHMS PCT LIA method. Information for identification of low-risk infants using RC was obtained. Negative predictive value, sensitivity, specificity, and likelihood ratio of PCT were compared with the RC. In univariate analysis, the components of RC and PCT were considered. Variables holding a significant association with the absence of SBI were included in a backward stepwise logistic regression model with SBI as the dependent variable, creating new low risk criteria. Results One hundred fifty-five patients were enrolled. Thirteen (8.4%) had an SBI. Procalcitonin concentration at a cutoff value of 0.26 ng/mL is similar in sensitivity (92%) and better in specificity (64%) than RC. A combination of urine white blood cell and PCT was the best model in the regression analysis. Conclusions Procalcitonin concentration is a serological marker for identification of or exclusion of SBI in infants aged 2 to 60 days. The predictive value of PCT in combination with urinary white blood cell count may be clinically useful. A validation study is indicated.